McGuenness, Warren 1'
�O 0 1
PtNE Y(EW CEMETERY ,,ND �23UT T
QU'`X-F3t ROAD, CREMATORIUM
QVEFNSBIlRY KEW YORK 12804
(518) 745•4476 (518) 745'.4477
am e Funeral Director
Warr�h �cCv¢nn¢ss
Baser
of CrematSon
� sr 7 �OG7
" e Cremation S 7Ced
Ctemation Completed 2 ICtOh
:e Of Container ( 4nq�oa
� eTa , �xs CASF_
i tz io p�
Cop
�t7
�2
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
A/C- C 0
(Name) (Sex)
3 0 r✓ 3 l 2-eo y
(Street) (City) (State) (Zip Code)
who died on (9 day of "7— 20
at Y_ t 1 L ^r.i ( Z /
(Place) (Address)
Name7,ddress of nearest livi relative or name of person authorizing .
6-AJ i U CJ- /9/7
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the hest of my krowledge,the deceased(has) (has no) akin,defibrillator or any other battery operated
device in his or her body. (Circle One)
i certify that 1 have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated rem,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save View Crenwkx tun from arty and aN clairrrs and demands for loss or damages which maybe made against them
by reason of corwxxled with the of said remeits as directed,whether such claims or demands are or are not wholy
� or
(
(Signature and Address of elatiivve or Legal Representative)
Signed on this date:
Dispositon of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here
Revision:January 1,2006